Wednesday, February 2, 2011

Today I'm reflecting on what it is that differentiates a great physician from a not-so-great one from a nursing perspective. Working in a teaching hospital you deal with all types of MD's. Interns, residents, fellows, attendings... starting in that order from lowest to highest on the hierarchy... we get them all. Working night shift in the ICU we also have an on-call team that is here 24-7. Depending on what the night is like we will always have at least an intern and a resident on the premises. If the night is nutty and we have a lot of admissions or very unstable patients, the ICU fellow will usually stick around throughout the night as well.

It's been a while since I've dealt with a difficult intern or resident... to be honest the teams that have been rotating through have been really great and the doctors have worked along aside the nursing staff so well, which I'm so thankful for. Tonight though, I came head to head with a resident and intern that reminded me just how frustrating it can be to have a not-so-great team. At the moment, all the nurses on the unit are counting down the days until this rotation is over... kind of unfortunate really.

Now before I go into my rant about all the things that make a not-so-great MD I will say this... I get that there are not-so-great nurses too. I also get that during your residency you are sifted through so many places and units and services... each with their own set of protocols and "this is how we do it around here" politics and junk. The culture of every hospital and even every unit can be so incredibly different. I can see how it would be really tough and exhausting to adjust and learn in so many different places.

I know that all of the doctors I work with have dealt with probably some really not-so-great nurses and I assume that can make you a little leery of trusting or working on a peer level with other nurses in the future...

BUT...

I feel there are a few suggestions for future MD's or MD's in their residency that will get you some brownie points with the nurses you work with.
1. I've said this before but humility will get you far. Coming into a unit that you've worked in for a mere two weeks and talking to a nurse who has worked there for 30 years with a condescending tone... not a good idea. Having a superior attitude and an "I'm the doctor so you WILL follow my orders" air about you.... not a great idea either. In fact its a terrible idea. With the exception of a few, most of the nurses I have worked with are very intelligent and I think people underestimate just how much we have to know as nurses. We know how things work in our unit. We know what the attendings usually want and what the surgeons prefer with their patients. We have a knowledge of physiology and disease processes and medications that is probably more than most medical students and interns expect. A little respect and trust is all I'm asking for here... and that takes humility from both sides of the fence.

2. Learn how to communicate. I think 1 and 2 go hand in hand here. In order to communicate well it takes humility. What I have noticed is that most of the time when someone is over confident and condescending towards others its because they are insecure and are over-compensating by having a massive power trip. Or maybe you're just a jerk... still.. learning how to communicate on a professional level with your colleagues and patients is key.

3. Teachability...
Huge! Ok... I know you are a doctor and I know you had to do massive amounts of schooling to become a doctor. I'm giving you the benefit of the doubt that you are brilliantly smart and motivated and hard working... I mean you made it through med school, passed your boards and you are in a very prestigous residency... thats all fine and dandy but you are not God and you do not know everything. I don't either... trust me... I deeeeefinitely don't. Still, most of the nurses I work with have years and years and years of clinical experience that any physician can draw off of. If we can't teach other and work with each other's strengths and weaknesses we are gonna get no where fast. And let me tell you... if you treat a nurse like he or she is beneath you and doesn't know anything and you know everything... you will make an enemy... Guar-OWN-teed... as gradydoctor puts it. :)
Ok basically just be respectful, humble and learn to listen to those around you... those three things go a long way in the nursing world.

Example for you all:
When I came into work tonight, I found out I had the post-op heart surgery patient and I was ecstatic... until... he began dropping his blood pressure and started shivering like mad... flopping in the bed like a fish out of water. His peak pressures were increasing on the ventilator, he was clamping down on his ET tube and he was fighting the vent like there was no tomorrow. All really not good things... things that could cause this guy to seriously crash on us if we don't treat it ASAP. So...I hunt down my resident and intern and I ask for some demerol to stop the tremors (usually caused as a reaction to anesthesia) and help sedate the patient so he wouldnt fight the ventilator and bottom out his pressures by "clamping down."

Their response?

"Just go up on the neo (med that helps increase blood pressure) and increase the sedation."

"Ok well he is already on 5 of versed and 500 of fentanyl and thats maxed out and its still happening. Plus CT surgery doesn't like us using neo on their patients because of the vasoconstriction and I wouldn't feel comfortable titrating up unless we got the okay from the CT fellow. I think if we gave him demerol he would stop fighting the vent. I could always give him some fluid too. His CVP is only 10 and CT usually likes it around 12 at least."

"No. Give the sedation more time to set in and just go up on the neo." the resident stands with his back towards me, arms crossed and continues his conversation with the intern.

Awesome. Apparently I don't even deserve to be looked at while you bark orders at me and refuse to listen to basically anything I just said.

You all can probably guess what the night was starting to look like for me. It was only an hour into my shift and I was already irritated. Luckily the ICU fellow came by at the time so I pulled him into my room and showed him what was going on. The intern and resident see him at the bedside and rush into the room to see why I was talking to the fellow and not them. I'm sure they could see that I was clearly frustrated at this point and I was about to go above their heads to get what I wanted.

All it took was a few seconds for the fellow to look at the patient and say, "How about I give you some demerol? Do you think 50mg IV is ok?"

"Perfect! Thats all I wanted!" I throw my hands up in the air and head towards our med station.

"And in the meantime let's give him a 500cc bolus of LR for his pressures."

What a sigh of relief! All I could think was, "Thank goodness for the fellow and thank goodness for doctors that actually listen to the nurses and don't treat us like we are completely inept!"

The rest of the night I had respiratory therapists and nurses coming in and out of my room to rant about how frustrating it was working with this on-call team and this particular rotation of docs. The rest of the shift ended up being fine for me but it got me thinking about the way you present yourself to people and the way you communicate and how it can completely change a team dynamic. Also it can just simply make your life miserable when you alienate the very people who are helping you and it's so unnecessary.

Now if you really want a good laugh... see the list of ways to make your life completely miserable in the hospital, on gradydoctor's post here. I was dying of laughter the entire time I was reading it.

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